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CASE REPORT
Year : 2022  |  Volume : 20  |  Issue : 2  |  Page : 107-108

Use of prasugrel in patients with clopidogrel hypersensitivity


1 Department of Cardiology, Coronary Care Unit, BLK Hospital, New Delhi, India
2 Hima Bindu Hospital, Hyderabad, Telangana, India

Date of Submission05-Feb-2022
Date of Decision24-Feb-2022
Date of Acceptance11-Mar-2022
Date of Web Publication07-May-2022

Correspondence Address:
Dr. Darpanarayan Hazra
Department of Cardiology, Coronary Care Unit, BLK Hospital, Pusa Road, Radha Soami Satsang, Rajendra Place, New Delhi - 110 005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_19_22

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  Abstract 


Allergic response to clopidogrel is a significant and difficult clinical problem as it is one of the recommended drugs after coronary stenting to prevent thrombosis. We present the case of a 57-year-old man who underwent coronary revascularization and developed an urticarial rash after being started on dual antiplatelet medication (aspirin and clopidogrel). He was managed conservatively, to which he responded well and was discharged on prasugrel. This case study from India adds to the available literature and discusses the alternative drugs that could be used in patients with clopidogrel hypersensitivity.

Keywords: Adverse drug reaction, clopidogrel-induced hypersensitivity reaction, hypersensitivity reaction, urticarial rash


How to cite this article:
Joshi A, Hazra D, Nekkanti AC. Use of prasugrel in patients with clopidogrel hypersensitivity. Curr Med Issues 2022;20:107-8

How to cite this URL:
Joshi A, Hazra D, Nekkanti AC. Use of prasugrel in patients with clopidogrel hypersensitivity. Curr Med Issues [serial online] 2022 [cited 2022 Jul 4];20:107-8. Available from: https://www.cmijournal.org/text.asp?2022/20/2/107/344931




  Introduction Top


Clopidogrel, a thienopyridine antiplatelet agent, works by binding irreversibly to the P2Y12 receptor and inhibitingAdenosine diphosphate (ADP)-induced platelet aggregation.[1] Clopidogrel-induced hypersensitivity typically manifests as a pruritic rash, which affects 4%–6% of individuals using the drug.[2] However, it is one of the most often prescribed antiplatelet medications and prevents stent thrombosis following percutaneous cardiac intervention (PCI), when combined with aspirin (PCI). It is also commonly used to prevent further vascular events in patients with ischemic heart disease, cerebrovascular accidents, or known peripheral arterial occlusive disease. In this article, we describe the clinical scenario and alternative management (prasugrel) of a 57-year-old man who developed an urticarial rash after using clopidogrel and is presently (1 year) doing well.


  Case Report Top


A 57-year-old male presented to the Emergency Department (ED) with complaints of central chest pain radiating to the left shoulder and nape of the neck for 5 h. He was previously diagnosed to have diabetes mellitus and was on an oral hypoglycemic agent. General and systemic examinations were within normal limits. Electrocardiogram revealed an ST elevated acute anterior wall myocardial infarction, for which he was immediately initiated on clopidogrel, aspirin and a high-dose statin in ED, in accordance with the American Heart Association practice guidelines.[3] Following this, he underwent a coronary angiography and PCI with a drug-eluting stent to the left anterior descending artery. Postprocedure, he was initiated on dual antiplatelet therapy. However, with the first dose of clopidogrel in the intensive care unit, he developed a purpuric, nonblanching, urticarial rash over his hands and back. There were no features of respiratory compromise, angioedema, gastrointestinal (GI) complaints, syncope, drop in blood pressure, or leukopenia. He was managed with intravenous chlorpheniramine maleate and hydrocortisone to which he responded well. Clopidogrel was stopped and he was thereafter initiated on prasugrel and discharged in a stable hemodynamical condition. At 1-year follow-up, no side effects were noted from the use of prasugrel. The patient gave his consent to use his clinical information to be reported in this journal.


  Discussion Top


Thienopyridines, particularly clopidogrel, are recommended for preventing coronary stent thrombosis, however, there is little information on hypersensitivity reactions following the usage of these drugs.[1],[2] During the first 2 weeks of treatment, when the risk of stent thrombosis is highest, this adverse drug reaction is most common. Clopidogrel allergy usually develops as a pruritic rash that affects 4%–6% of people taking the drug and causes 1.5% of patients to stop using it.[2] Fever, leukopenia, thrombotic thrombocytopenic purpura, aplastic anemia, angioedema, serum sickness, systemic inflammatory response syndrome, and end-organ destruction have all been reported in the literature as more severe hypersensitivity syndromes.[4],[5] It can be difficult to diagnose clopidogrel hypersensitivity, as there are no validated, sensitive antibody-based laboratory diagnostics for the same.[2] Symptom relief with drug withdrawal and recurrence with repeat challenge can be used as markers to make a clinical diagnosis. However, simultaneous administration of numerous drugs, iodinated contrast, and drug-impregnated stents can complicate the arrival of a definitive clinical diagnosis.

True hypersensitivity reactions are caused by an IgE-mediated immunologic response to an antigen. A case of clopidogrel hypersensitivity was described by Vigo et al. in a patient who had a positive clopidogrel intradermal skin test, indicating an IgE-mediated immunologic response.[6] T-cell activation, direct mast-cell or complement activation, or immunological complex formation by the drug or one of its metabolites may all play a role in clopidogrel cross-reactivity, although the specific mechanism is unknown.

Clopidogrel cessation carries a 25%–29% risk of subacute stent thrombosis causing significant mortality in the setting of recent PCI, thereby making prasugrel a viable alternative since its FDA clearance in 2009.[7] Ticlopidine, the first thienopyridine, had clinical limitations due to its high rate of side effects and adverse reactions such as diarrhea, rash, nausea, vomiting, GI pain, and neutropenia. According to the recent research review, those who took prasugrel had a considerably lower risk of stroke, myocardial infarction, or death than those who took ticlopidine.[8],[9] There was no statistically significant difference in the incidence of major bleeding between the two groups. In addition, our literature review also showed that prasugrel reduced cardiovascular mortality, the incidence of an acute coronary syndrome, stent thrombosis, and stroke more effectively than clopidogrel. However, it comes with a larger risk of bleeding, making clopidogrel the first-line drug in patients following coronary revascularization.[9],[10] After an adequate literature search and medical consensus, our patient was switched to prasugrel, which he tolerated well for a year without any side effects.


  Conclusion Top


This report emphasizes the significance of carefully considering a variety of patient-and drug-specific aspects when choosing the best dual antiplatelet treatment for patients with adverse reactions to clopidogrel. However, more research is warranted for an evidence-based conclusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pereira NL, Rihal CS, So DY, Rosenberg Y, Lennon RJ, Mathew V, et al. Clopidogrel Pharmacogenetics. Circ Cardiovasc Interv 2019;12:e007811.  Back to cited text no. 1
    
2.
Lokhandwala J, Best PJ, Henry Y, Berger PB. Allergic reactions to clopidogrel and cross-reactivity to other agents. Curr Allergy Asthma Rep 2011;11:52-7.  Back to cited text no. 2
    
3.
Campbell-Scherer DL, Green LA. ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction. Am Fam Physician 2009;79:1080-6.  Back to cited text no. 3
    
4.
Comert A, Akgun S, Civelek A, Kavala M, Sarigül S, Yildirim T, et al. Clopidogrel-induced hypersensitivity syndrome associated with febrile pancytopenia. Int J Dermatol 2005;44:882-4.  Back to cited text no. 4
    
5.
Sarrot-Reynauld F, Bouillet L, Bourrain JL. Severe hypersensitivity associated with clopidogrel. Ann Intern Med 2001;135:305-6.  Back to cited text no. 5
    
6.
Vigo PG, MacDowell AL, Wedner HJ. Successful desensitization with clopdogrel after a positive skin test. Ann Allergy Asthma Immunol 2005;94:132.  Back to cited text no. 6
    
7.
Spertus JA, Kettelkamp R, Vance C, Decker C, Jones PG, Rumsfeld JS, et al. Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: Results from the PREMIER registry. Circulation 2006;113:2803-9.  Back to cited text no. 7
    
8.
Peppard SR, Held-Godgluck BM, Beddingfield R. Use of prasugrel in a patient with clopidogrel hypersensitivity. Ann Pharmacother 2011;45:e54.  Back to cited text no. 8
    
9.
Chen W, Zhang C, Zhao J, Xu X, Dang H, Xiao Q, et al. Effects of clopidogrel, prasugrel and ticagrelor on prevention of stent thrombosis in patients underwent percutaneous coronary intervention: A network meta-analysis. Clin Cardiol 2021;44:488-94.  Back to cited text no. 9
    
10.
Eisenstein EL, Anstrom KJ, Kong DF, Shaw LK, Tuttle RH, Mark DB, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007;297:159-68.  Back to cited text no. 10
    




 

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Case Report
Discussion
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